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Effect of Physiotherapy Treatment on Frozen Shoulder: a Case Study

Article · January 2015

DOI: 10.5958/0973-5674.2015.00028.3

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 DOI Number: 10.5958/0973-5674.2015.00028.3

Effect of Physiotherapy Treatment on Frozen

Shoulder: a Case Study

Punia Sonu1, Sushma2

1
Teaching Associate , Student, Department of Physiotherapy, Guru Jambheshwar University of Science and Technology
2

Hisar (Haryana)

ABSTRACT

Objective: To determine the effectiveness of physiotherapy management in patients with frozen

shoulder.

Materials and Method: A rehabilitation protocol was followed to treat diagnosed frozen shoulder patient.
Result: In this study, Reduction in pain, improvement in range of motion and able to do activities of
daily living after giving physiotherapy management.

Conclusion: this study concluded that Various therapeutic techniques like hot packs, ultrasound,
capsular stretches, strengthening exercises and home regime have a significant effect in reducing pain,
increasing range of motion and stiffness of joints in frozen shoulder.

Keywords: Frozen shoulder, Physiotherapy.

INTRODUCTION Frozen shoulder was first described as

Frozen shoulder is also termed as adhesive
capsulitis, stiff painful shoulder, or periarthritis
is a common cause of shoulder pain is a common
cause of shoulder pain. It is estimated to affect 2-
5% of the general population.1 Frozen shoulder is
a rheumatological enigma.2 Frozen shoulder is a
ill-understood disorder. It affects the glenohumeral
joint, possibly involving a non-specific chronic
inflammatory reaction, mainly of the subsynovial
tissue, resulting in capsular and synovial thickening.
Frozen shoulder is used to denote a limitation of
shoulder motion without abnormalities of the joint
surface, fracture or dislocation. The onset of frozen
shoulder is usually gradual and idiopathic. The
disease occurs mainly in middle aged individuals and
is usually self-limiting but the duration and severity
may vary greatly.3 Most studies have suggested a self
limiting condition lasting an average of two to three
years, although significant numbers of people have
residual clinically detectable restriction of movement
beyond three years and smaller numbers have
residual disability.1
periarthritis by Duplay in 1872. Codman coined the
termed as ‘frozen shoulder ’in 1934. J.S.Naviaser
coined the term ‘adhesive capsulitis’ in 1945. He
found dense adhesions and capsular contractures
causing in restriction of motion, intra-articular pain
and microscopic evidence of reparative inflammatory
changes in the glenohumaral joint capsule.
Many authors have a�empted to explain the
cause of frozen shoulder. Some have suggested an
autoimmune phenomenon. Others have suggested the
condition is a variant of sympathetic reflex dystrophy.
However, patients generally do not improve after
what is probably the most effective treatment for
sympathetic reflex probably the most clinically useful
classification of the frozen shoulder defines primary
and secondary forms. In the primary form, no other
identifiable systemic condition or local shoulder
disease explains the patient’s pain and loss of range
of motion. Most of the literature on diagnosis and
treatment refers to the primary form. In the secondary
form, a predisposing condition usually is associated
with the patient’s pain and loss of movement. Patients
with hemi paresis from a stroke or other upper motor
 Indian Journal of Physiotherapy and Occupational Therapy. January-March 2015, Vol. 9, No. 1
neuron lesion frequently develop a secondary frozen
shoulder. Frozen shoulder might coexist with other
local shoulder disorders, such as impingement
syndrome. Other predisposing conditions include
cervical spondylosis, recent thoracic surgery, thoracic
(such as a Pancoast tumor), and coronary artery
disease.5
Information on the treatment and prognosis
of frozen shoulder is inadequate and based largely
on individual practice experience rather than
randomized controlled clinical trials. There is as
yet no definitive agreement on the most effective
form of treatment. Initial treatment is aimed at
reducing inflammation and increasing range of
motion. Thus analgesic and anti-inflammatory
drugs are commonly used. Most type of treatment
focus primarily on restoration of mobility. Although
physical therapies such as massage, heat application,
ultrasound, interferential treatment, osteopathic
, chiropractic techniques and stretching and
isometric exercise therapy are routinely prescribed,
the efficacy is variable. Controversial results are
reported with manipulation under anesthesia,
distension arthography, and arthoscopic surgery. In
osteoporotic or postsurgical frozen shoulder, an open
release with lysis of adhesions and capsule release is
recommanded. Intra-articular corticosteriod injection
and suprascapular nerve block have also been
strongly advocated. Metaanalysis of randomized
controlled trials evaluating interventions for painful
shoulder from 1966 to 1995, however, failed to find
evidence to support or refute the efficacy of these
interventions.
Acupuncture has been reported to be effective
for the treatment of frozen shoulder or shoulder
arthritis. Hansen reported that 5 minute acupuncture
treatment sessions were equally as effective for neck
and shoulder pain when compared with 20 minute
sessions. However, there was an imbalance between
the groups studied in terms of the pretreatment visual
analogue score, and this combined with the limited
trial size suggested these results may not be reliable.4
Manipulation under anesthesia combined with
early physiotherapy alleviates shoulder pain and
facilitates of shoulder function in patients with frozen
shoulder syndrome.
137
Conservative management strategies for frozen
shoulder frequently include combination of varied
types of interventions such as rest, medications,
acupuncture, physical agents, postural or ergonomic
advice, slings and range of motion exercise programs.
Therapy includes manual therapy; ROM exercises,
specific stretching and strengthening exercises and
aerobic program and modalities are available such as
interferential therapy, ultrasound, and hot therapy.
There is no doubt that physiotherapy treatment is
promising and cost effective treatment option and
aimed at relieving the pressure on nerves causing
the inflammation and pain. This present study is
done on patients’ diagnosed frozen shoulder with a
physiotherapy treatment protocol.
RELEVANT ANATOMY, ETIOLOGY AND
PATHOLOGY OF SHOULDER
The shoulder is a complex, ball and socket
synovial joint, composed of the humerus, scapula
and the clavicle. The labrum is a ring cartilage that
surrounds and deepens the glenoid cavity of the
scapula. The resting position of the glenohumeral joint
is 550 of abduction and 300 of horizontal adduction.
What makes the shoulder unique among all the joints
of the body is that its support, stability and integrity
depend on muscles rather than bones and ligaments.
However recent studies have shown that it is the
group of muscles known as the rotator cuff that is most
commonly involved in myofascial pathologies of the
shoulder. The rotator cuff muscle group is comprised
of the supraspinatus, infraspinatus, teres minor and
subscapularis muscles. According to Klab, 95% of all
cases of shoulder pain are a�ributable to the tendons
of the rotator cuff becoming impinged between the
greater tuberosity of the humerus and the anterior
edge of acromion, especially during motions that
positions the arm above the head. Thus, impingement
syndromes are the most frequent type of shoulder
pathology and often the result of the cumulative
effect of the rotator cuff tendons constantly passing
under the acromion hood.6
ETIOLOGY
The etiology of the frozen shoulder remains
unknown. Lundburg and helbig et al proposed
primary and secondary classifications for cases that
occur spontaneous and for those that results trauma.
138 Indian Journal of Physiotherapy and Occupational Therapy. January-March 2015, Vol. 9, No. 1
The primary, idiopathic cases are the most common
and the least understood. The unknown stimulus
produces profound histological changes in the capsule
that are substantially different from changes produced
by immobilization and degeneration. Secondary
frozen shoulder commonly develops after a variety of
antecedent episodes, such as central nervous system
involvement, upper limb immobilization, and trauma
to the arm, pulmonary cancer or infection, myocardial
infarction, lengthy duration of intravenous infusion,
cervical disk disease, rheumatoid arthritis, or diabetes
mellitus. Quigley hypothesized that minor trauma or
an episode of inflammation may produce pain, which
eventually leads to disuse and the classical restriction
of motion characterizing frozen shoulder. Lloyd and
Lloyd suggested that secondary frozen shoulder
develops when painful spasm limits activity and
creates dependency of the arm.
PATHOLOGY
Features of this pathologic condition include
chronic capsular inflammation with fibrosis
and perivascular infiltration. Although several
researchers found no evidence of inflammation, they
concurred that fibrosis exists in the capsule. Chronic
cases of frozen shoulder demonstrate constrictive
capsulitis, characterized by adhesions of synovial
folds; obliteration of the joint cavity; and a thickened,
contracted capsule that eventually becomes fixed to
the bone.7
BIOMECHANICS OF SHOULDER JOINT
Complex shoulder joint is comprised of mainly
three joint glenohumeral joint, stenoclavicular
joint and acromioclavicular joint. The coordinating
movement of these joint during arm movement is
referred to as scapulahumeral rhythm. Inman and
Colleagues in 1944 showed the kinematics of the
shoulder abduction, occurring at a ratio of 2:1. a full
arc of 1800 of shoulder abduction is the result of a
simultaneous 1200 of glenohumeral joint abduction
and 600 of scapulothoracic upward rotation. Stage
1 includes Glenohumeral movement alone for first
30O, inferior angle of scapula should not move
and Clavicle elevate 5 O. Stage 2 includes Scapular
elevation and upward rotation (200) point glenoid
cavity towards the ceiling humeral head glides
inferiorly by 90O revealing a sulcus. Stage 3 includes
60 O degree abduction, 90 degree lateral rotation of
humerus, 30O rotation of scapula and 30-50O rotation
up to 15 degree elevation of clavicle.8
DIAGNOSIS
The natural history of frozen shoulder follows a
classic cycle of “freezing”, “frozen”, and “thawing”.
There is an acute onset of pain that often worsens
during the first weeks or months. The pain of
frozen shoulder is present during both activity
and rest, resulting in long term sleep disturbances.
Arm movement of the shoulder also aggravates the
symptoms. Limitation of the shoulder motion is the
frequent symptom. Motion is guarded, and the arm is
held against the body with the shoulder adducted and
medially rotated. Functional activities that requires
overhead reaching or behind the back may be difficult
or impossible because of pain. Disuse atrophy may
be evident in the rotator cuff. Capsular contractures
limit the range and thus, produce a capsular end feel7.
Both Yergason’s test11 (resisted forearm supination
with elbow flexed to 90’) and Speed’s test12 (resisted
shoulder forward flexion) are often positive. Other
pathologies commonly found in the shoulder
involve the muscles or tendons of supraspinatus,
subscapularis and deltoid. These can be differentiated
by the Empty can test (resisted abduction with arm at
90’ abduction and medial rotation) and Lift-off sign
(patient asked to lift hand off his or her lower back)
and drop-arm test respectively.13
MANAGEMENT
Many treatments have been advocated for
frozen shoulder. The existence of so many different
treatments, each with its own group of enthusiastic
supporters, suggests that no single treatment is
unequivocally superior to others. The fundamental
goal of treatment is to restore and maintain function.
Corticosteroid injections have long advocated for
treating frozen shoulder joint, into the adjacent soft
tissues, or into the subacromial bursa1. Many studies
have included early mobilization and gentle range
of motion exercises should be part of managing all
patients with shoulder dysfunction. Exercise should
be two types stretching exercises to prevent further
loss of range of motion and promote faster return to
normal range, and strengthening. A physiotherapist’s
most useful role is in patient education and instruction
 Indian Journal of Physiotherapy and Occupational Therapy. January-March 2015, Vol. 9, No. 1
in appropriate exercise to prevent loss of further
range and strength5.Among all the above treatments
physiotherapy play a significant role in the treatment
of frozen shoulder. After through assessment
physiotherapy rehabilitation protocol was given to
the patients. The protocol is as follows4.
PHYSIOTHERAPY MANAGEMENT (15
SESSIONS WERE GIVEN)
DAY 1-5
• Hot packs for 15 minutes so as to relax the muscles
around shoulder complex.
• Ultrasonic therapy: 0.8 wa�s with 1 MHz frequency
probe for 10 minutes for breaking the adhesions as
well as relieving pain.
• Shoulder joint capsule stretching (4 times)
• GH Caudal glides (4sets of 10 rep. each)
• GH Posterior glides (4 sets of 10 rep. each)
• Long axis traction of glenohumeral joint (5 mins)
• Passive movements
• Finger ladder exercise
• Shoulder wheel exercise for 15 minutes
• Home regime
• Hot water fomentation
• Pendular exercises
• Wall finger climbing exercises
• Self assisted exercise.
DAY 6-10
Exercises are same while number of repetitions is
increased
• Shoulder joint capsule stretching (6 times)
• GH Caudal glides (6 sets of 10 rep. each till end
range)
• GH Posterior glides (6 sets of 10 rep. each till end
range)
• Long axis traction of glenohumeral joint (7 times)
• Hold relax exercises (7 repts)
• Resisted exercises in available range are added (10
repts)
DAY 11-15
Exercises are kept same and the numbers of repetitions
are increased.
• Hold relax exercise (10 repts)
139
• Resisted exercises in available range are added (15
repts)
PROCEDURE
5 patients (3 females 2 males) diagnosed case
of frozen shoulder were randomly included in the
study. They were assessed by a fixed assessment
protocol prior to the commencement of the study.
Subjects included whom had Painful, restricted
active and passive range of motion of the shoulder,
symptoms present for at least 1 month, absence of
radiological evidence of glenohumeral joint arthritis
and had capsular pa�ern of motion restriction.
Subjects were excluded if any subject had taken local
corticosteroid therapy currently and within the last
3 months, and had history of any neuromuscular
diseases, Pregnancy and diagnosis of cancer within
12 months10.
DISCUSSION
Frozen shoulder is often diagnosed and
managed. This is partially due to a lack of agreement
about definitions and classification of this disorder,
confusing terminology and difficulty differentiating
it from other conditions. The frozen shoulder is
characterized by an unknown etiology, spontaneous
and gradual onset of pain and a global restriction
of movement in the GH joint due to contractures
and loss of compliance of the capsule. While the
etiology is typically unknown, there can be a history
of minor trauma and occasional significant injury.
An important component of successful management
of frozen shoulder syndrome is educating patients
and informing them about the planned treatment
modalities. Objectives of physiotherapy and
rehabilitation applications in patients with frozen
shoulder are to prevent disability, to increase
functional capacity, and to provide pain relief .In
this study five cases of frozen shoulder were taken, 3
females and 2 males. The age of patients were ranging
from 35-60 years. All of them suffered from global
restriction of movements and pain in the shoulder
region. Patients also displayed a feature of nocturnal
pain in common. A standardized assessment
performa was used to assess the patient.
Case 1 presented with pain and stiffness in
left shoulder, global restriction of movements and
difficulty in ADL’s .VAS score was 7 before treatment
 140 Indian Journal of Physiotherapy and Occupational Therapy. January-March 2015, Vol. 9, No. 1
and after physiotherapy treatment reduced to 3. Pain
reduced and also stiffness in joint was reduced. She was
able to activities of daily living. Case 2 presented with
pain and stiffness in right shoulder, nocturnal pain,
and restriction of movements. VAS score was 8 before
treatment and after physiotherapy treatment was
reduced to 4. Pain was reduced and also the stiffness
in joint, range of motion increased. Case 3 presented
with pain and stiffness in shoulder, nocturnal pain
and global restriction of movements. VAS score before
treatment was 8 and after physiotherapy treatment
were 5. Joint stiffness was reduced and patient was
able to do activities of daily living. Case 4 presented
with pain and stiffness in shoulder, severe pain during
sideways lifting, diabetic and history of trauma was
there. VAS score before treatment was 8 and after
physiotherapy treatment was reduced to 4. Pain was
reduced, improved range of motion and he was able
to do activities of daily living. Case 5 presented with
stiffness and pain in shoulder, limitation of overhead
and sideways movements, nocturnal pain. VAS scale
before treatment was 7 and after physiotherapy
treatment were 3 and reduction in pain, improvement
in range of motion and able to do activities of daily
living. All the patients were given physiotherapy
treatment according to the condition for example
ultrasound, hot packs, shoulder mobilization, capsule
stretching, strengthening exercises for weak muscles
and pain relief. Prognosis was found to be very
effective after physiotherapy treatment.
CONCLUSION
The cases studied shows that physiotherapy plays
an important role in treatment of patients suffering
from frozen shoulder. Various therapeutic techniques
like hot packs, ultrasound, capsular stretches,
strengthening exercises and home regime have a
significant effect in reducing pain, increasing range of
motion and stiffness of joints in frozen shoulder.
Acknowledgement: The authors are thankful to
subjects who participated in this study to carry out
this work.
Source of Funding: The work done in the study
has not been supported by any funding agency or
supported by a grant and it has not been adapted
from a conference presentation.
Conflict of Interest: There was no conflict of interest.
View publication stats
Ethical Clearance : The research was approved
from the ethical commi�ee of department of
physiotherapy, guru Jambheshwar University of
science & technology, hisar.
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